TESOL Certificate Checklist Graduate Advanced TESOL Certificate Program Application Save my progress and resume later | Resume a previously saved form Resume Later In order to be able to resume this form later, please enter your email and choose a password. Your Email: A Password: Confirm Password: Page 1 Advanced TESOL Certificate CampusPortland Program of StudyPlease select... Graduate Advanced TESOL Certificate Admission forPlease select... Fall 2019 (August) First Name Middle Name Last Name Preferred First Name (If Different) Have you gone by any other legal names? (such as a maiden name) Email Cell Phone Home Phone Allow Text Messages Allow Do Not Allow Mailing Address City Please select... AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MP MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VT WA WI WV WY Outside the US AA AE AP AS DC FM GU PW VI State Zip Code Ethnic & Racial Information (Optional) Are you Hispanic/Latino? Yes No Optional - this information will not be a factor in your admission decision Please select one or more of the following races:American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhite or Caucasian Optional - this information will not be a factor in your admission decision Additional Personal Information Are you a U.S. Citizen? Yes No Are you a U.S. Permanent Resident? Yes No An international student is one who will be attending a university in the United States without residency or citizenship, typically on an F-1 visa. International students have additional application requirements as part of the Visa application process, often including an English language proficiency exam and transcript evaluation by an evaluation service. The admissions department can assist with questions about this process. Country of CitizenshipPlease select... United States of America Canada Afghanistan Albania Algeria Andorra Angola Antigua Argentina Aruba Austria Australia Azores Bahamas Bahrain Balearic Islands Bangladesh Barbados Belgium Belize Benin Bermuda Bhutan Bolivia Botswana Brazil Brunei Bulgaria Burkina Faso Burma Burundi Cambodia Cameroon Canal Zone Canary Islands Cape Verde Islands Cayman Islands Central African Republic Chad Chile Peoples' Republic of China Colombia Comoro Islands Congo Cook Islands Corsica Costa Rica Cote d'Ivoire Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador England Equatorial Guinea Estonia Ethiopia East Timor Faroe Islands Fiji Islands Finland France French Guiana French Polynesia Gabon Gambia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guatemala Guinea-Bissau Guinea Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea Kuwait Laos Latvia Lebanon Leeward Islands Lesotho Liberia Libya Liechtenstein Lithuania Laos Luxembourg Macao Republic of Macedonia Madeira Islands Malagasy Malawi Malaysia Maldives Mali Malta Martinique Mauritania Mauritius Mexico Federated States Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherland Antilles Netherlands Nevis New Britain New Caledonia New Hebrides New Zealand Nicaragua Niger Nigeria North Korea Northern Ireland Norway Okinawa Pakistan Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Principe Qatar Reunion Islands Romania Russia Rwanda Ryukyu Islands Saudi Arabia South Africa Scotland Senegal Seychelles Islands Sierra Leone Sikkim Singapore South Korea Slovakia Slovenia Solomon Islands Somolia Spain Spanish North Africa Spanish Sahara Sri Lanka Santa Cruz Islands St. Kitts St. Lucia St. Thomas St. Vincent Sudan Sultanate of Oman Suriname Southwest Africa Swaziland Sweden Switzerland South Yemen Syria Taiwan Tanzania Thailand Tobago Togo Tonga Trinidad Turks Island Tunisia Turkey Tuvalu Uganda United Kingdom Ukraine United Arab Emirates Uruguay Vatican City Venezuela Vietnam Virgin Islands Wales Windward Islands Western Samoa Yemen Yugoslavia Zaire Zambia Zimbabwe Date of Birth Gender Female Male Household Marital StatusPlease select... Single Married Separated Divorced Widow/Widower Spouse Information Relationship to youPlease select... Spouse First Name Last Name Email Please note: This email address should not match the email given for other individuals on this application. Entering the same email address as the applicant or other individuals on this form may result in a technical error. Does this person share your mailing address? Yes No Mailing Address City Please select... AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MP MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VT WA WI WV WY Outside the US AA AE AP AS DC FM GU PW VI State Zip Code Hidden Fields Student (Record Type) Constituent (Record Type) TypePlease select... Christian Character Reference Christian Character Reference Graduate and Seminary Household (Record Type) Educational Institution (Record Type) Page 2 Academic History College Have you completed a bachelor's degree?YesNoI will prior to beginning this program Have you completed at least 12 college level, foreign language credits?Please select... Yes No I will prior to beginning this program College or Graduate School Please list all institutions you have attended, beginning with the most recent. Institution Name City StatePlease select... AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MP MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VT WA WI WV WY Outside the US AA AE AP AS DC FM GU PW VI Attended from: Attended to: Are you currently enrolled at this institution?YesNo Approximate Credits Earned Degrees earned: Lifestyle Responsibilities Have you used illegal substances within the last year?YesNo Please explain Have you pled guilty (or no contest), been adjudicated, or otherwise been convicted of a crime or subject to a civil indictment or other disciplinary action? Yes No Do not include infractions such as speeding tickets. Please note that offers of admission may be revoked should additional information arise that indicates unlawful or unethical behavior. Criminal or Disciplinary Disclosure & Authorization to Release Information Because you indicated that you have a civil or criminal indictment, conviction, history and/or disciplinary action on this application, you will be asked to complete a background check once all of your application materials are received and processed.A previous disciplinary action, conviction, indictment or prosecution may not automatically bar an applicant from admissions to the university. We request that the applicant provide the Admissions Office permission to obtain a background check (at no cost to the student). By electronically signing below, the applicant authorizes Multnomah University to have complete access to pertinent educational, employment, criminal and civil information and records: Name: Date signed: Please provide a complete and detailed explanation regarding any civil or criminal indictment, conviction, history and/or disciplinary action: Multnomah's Doctrinal Statement Multnomah University welcomes students from a variety of denominational backgrounds. The University holds to a short list of doctrinal articles. Though it does not require students to be in agreement with all points, it is important that you be familiar with the university’s doctrinal statement, found at www.multnomah.edu/about/doctrinal-statement. I have read Multnomah's doctrinal statement and I am comfortable studying at an institution that holds to these positions. Yes No If not, please explain Have you committed your life to Jesus Christ as your personal Savior? Yes No Unsure Please explain Church Involvement Name of the Church you regularly attend DenominationPlease select... Non-Denominational American Baptist Assembly of God American Missionary Fellowship Anglican Baptist Bible Brethren Catholic Believer Catholic Conservative Baptist Church of Christ Congregational Christian Christian & Missionary Alliance Community Covenant Evangelical Church of North America Evangelical Free Episcopal Free Methodist Friends Foursquare General Conference Baptist Church of God Independent Ind Fundamental Churches of America Interdenominational Jewish Believer Jewish Lutheran Mennonite Brethren Methodist Nazarene Plymouth Brethren Pentecostal Presbyterian Protestant Believer Protestant Regular Baptist Roman Catholic Reformed Southern Baptist Seventh Day Adventist Unknown Village Missions Wesleyan Methodist Please explain City, State Essay Please submit an essay of at 300-500 words describing your relationship with Jesus Christ, and why you are interested in participating in the TESOL Advanced Certificate Program. Please enter your essay here: Page 3 Christian Character Reference Please provide the name and contact information for somebody who can serve as your Christian Character Reference. The admissions team will email your reference a form to complete on your behalf. This form should be completed by the your pastor, church leader, spiritual mentor, or a Christian who knows you well and can speak to your testimony and walk with Christ. It should not be completed by a relative.Your application file is not considered complete until a Christian Character Reference form has been received by the University's Admissions Office. Name First Name Last Name Phone Email Please note: This email address should not match the email given for other individuals on this application. Entering the same email address as the applicant or other individuals on this form may result in a technical error. In some circumstances, we may ask for an additional reference. If this is the case, your admissions counselor will let you know and request the additional information. Reference AuthorizationBy providing this information I am authorizing Multnomah to contact the person listed above as my Christian Character Reference. I understand that the information provided by my reference will be used as part of the admission decision process, and I waive my right to review this information. Decision Factors How did you first hear about Multnomah?Please select... Alumni Admissions Counselor College Fair Co-worker or Employer Current MU Student Friend Guidance Counselor or Teacher Google Search MU Faculty or Staff Parent or Relative Pastor Radio Visit to my high school Web advertisement Other Explain What is the primary factor influencing your decision to apply?Please select... Academic Programs Offered Academic Reputation Admissions Counselor Alumni Beliefs/Values Campus Event Campus Visit Classmate College Fair Co-worker or Employer Friend Guidance Counselor Location Mail or email communication MU Faculty or Staff Other Explain Name of the person who referred you (so we can thank them) Certification & Authorization $40 Application FeeI will pay my application fee online now using a credit or debit cardI will mail a check or money order for my application feeOther You can pay your application fee by check or money order mailed to:Admissions OfficeMultnomah University8435 NE Glisan StreetPortland OR 97220 You may pay your $40 application fee at www.multnomah.edu/payments. Links:Mission StatementStudent Life HandbookHuman Sexuality and Purity Understanding By submitting this application, I certify that I have provided complete and accurate statements on this application and I waive my right to see reference forms that are submitted on my behalf. I understand that if it is found to be otherwise, this may be cause for rejection or dismissal. I agree with the mission, goals, and core values of Multnomah University. I agree to abide by the guidelines, principles, and regulations published in the Multnomah catalog and student handbook. I understand that Multnomah seeks to be an alcohol-free, tobacco-free, drug-free, and sexually pure campus and I agree to live according to the Human Sexuality and Purity Understandings. Yes No Please type your full name in this box as a signature certifying the preceding statements are accurate and complete, to the best of your knowledge. Save my progress and resume later | Resume a previously saved form Need assistance with this form?